Finding 1228261 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-08-28
Audit: 409999

AI Summary

  • Core Issue: There are significant deficiencies in applying the sliding fee discount program, leading to inconsistent patient charges.
  • Impacted Requirements: Compliance with federal regulations under the Public Health Services Act is at risk due to errors in discount application.
  • Recommended Follow-Up: Reassess monitoring procedures for the sliding fee program, ensuring clear responsibilities and enhanced testing, especially for dental transactions.

Finding Text

Finding Number: 2025 002 Finding Type: Significant deficiency in internal controls over compliance and nonmaterial noncompliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Awards: H80CS04210 20 from May 1, 2024 through April 30, 2025 and H80CS04210 21 from May 1, 2025 through April 30, 2026 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which patient charges are adjusted based on the patient’s ability to pay. Condition: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments were applied based on individual procedure codes rather than the date of service. In one additional instance, an incorrect sliding fee adjustment was applied to the patient balance. Collectively, these three errors resulted in patients being charged $311 more than required under the Organization's sliding fee discount program. We also identified one patient who received a sliding fee discount without an active sliding fee application for the applicable date of service and was therefore not eligible for the $204 discount. Cause: The Organization lost the dental biller who performed a review of 100% of dental sliding fee adjustments. Upon the individual's departure, responsibility for this review was not assumed by other members of the billing team. Effect: Sliding fee discounts may not be consistently applied in accordance with the Organization's policy, resulting in potential noncompliance with federal program requirements if errors are not timely identified and corrected. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization reevaluate its monitoring procedures over the sliding fee discount program. The monitoring process should include clearly assigned responsibility for review, defined review frequency and sample sizes, and consideration of system-specific risks. Given the increased level of manual processing for dental transactions, monitoring should include enhanced testing of dental sliding fee adjustments. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. See corrective action plan.

Corrective Action Plan

Finding Number: 2025-002 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments were applied based on individual procedure codes rather than the date of service. In one additional instance, an incorrect sliding fee adjustment was applied to the patient's balance. Collectively, these three errors resulted in patients being charged $311 more than required under the Organization's sliding fee discount program. We also identified one patient who received a sliding fee discount without an active sliding fee application for the applicable date of service and was therefore not eligible for the discount. Individual(s) Responsible for Corrective Action: Dean Correnti, CFO Planned Corrective Action: Sliding fee schedule is completed by the Dental Practice Manager on a case-by-case status. On a monthly basis, they are to be presented to the CFO for him to sign off on to verify all is correct. Any adjustments will be made quickly and correctly. The current policy for sliding fees has been updated, reviewed, and signed off by all parties involved. Anticipated Completion Date: Completed on March 1, 2026

Categories

Special Tests & Provisions Subrecipient Monitoring Reporting Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1228260 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $4.12M
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $477,349
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $283,244
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $153,522
93.667 SOCIAL SERVICES BLOCK GRANT $94,415
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $77,367
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $25,281
93.556 MARYLEE ALLEN PROMOTING SAFE AND STABLE FAMILIES PROGRAM $24,630
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $19,481
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $16,991
93.991 PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT $12,079
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $11,512
93.008 MEDICAL RESERVE CORPS SMALL GRANT PROGRAM $5,846
93.645 STEPHANIE TUBBS JONES CHILD WELFARE SERVICES PROGRAM $4,105
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $534
93.391 ACTIVITIES TO SUPPORT STATE, TRIBAL, LOCAL AND TERRITORIAL (STLT) HEALTH DEPARTMENT RESPONSE TO PUBLIC HEALTH OR HEALTHCARE CRISES $87
93.889 NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM $-1,565